Wednesday, 27 June 2012

This morning the British Medical Association Annual Representative Meeting debated two motions on abortion and one on euthanasia.

Here is a record of the debates as they happened from the BMA blog.

Motion 328 called for the meeting to support the universal availability of non-directive counselling for women considering abortion.

It said that the counselling should be in accordance with NHS standards and independent of the abortion provider if women so wished.

328 Motion by THE AGENDA COMMITTEE (MOTION TO BE PROPOSED BY THE HARROGATE DIVISION):
That this Meeting:-
i) supports the universal availability of neutral counselling for women considering abortion;
ii) believes that any counselling provided for women considering abortion should accord with NHS standards;
iii) believes that women considering abortion should be able to access counselling that is
independent of the abortion provider;
iv) deplores picketing and intimidation around abortion services.

Dr Mark Pickering, in proposing the motion, said the issue was about extending choice for women, not limiting it.

Professor Wendy Savage responded that she had been the press officer for a woman's choice organisation for 35 years. She said it was 'an absolute insult' to professionals to require so-called independent counselling. She said the pros and cons would be explained in any operation. She said most 'independent' counsellors were not actually independent.

But the meeting supported the provision of non-directive counselling for women considering abortion and also condemned the picketing and intimidation around abortion services.

This is a great result for women facing the crisis of unplanned pregnancy and should encourage parliament to make moves in the direction of independent counselling provision.

Motion 329 called for the meeting to back a call stating that abortion on the grounds of gender alone is unacceptable.

329 Motion by THE AGENDA COMMITTEE (MOTION TO BE PROPOSED BY THE GREENWICH, AND BROMLEY DIVISION):
That this Meeting believes that abortion on the grounds of gender alone is unacceptable and demands that :
i) such practice should cease forthwith;
ii) the law should be changed to make this practice illegal in the UK.

GP Kackie Applebee said the meeting had to be careful about passing any issue that sought to limit abortion. She called on the meeting not to jeopardise a woman's right to choose.

But GP Paddy Glackin maintained that the motion was not a slippery slope. He was cheered as he said the motion was saying that female infanticide was a gross violation of human rights.

However, after a passionate debate the motion was judged ‘not competent’ and was not passed.

Motion 332 called for the BMA to adopt a neutral position on ‘assisted dying’.

I have previously argued on this blog why I believe that going neutral on assisted suicide would be a very dangerous move indeed.

332 Motion by THE AGENDA COMMITTEE (MOTION TO BE PROPOSED BY THE SHROPSHIRE DIVISION):
That this Meeting:-
i) believes that assisted dying is a matter for society and not for the medical profession;
ii) believes that the BMA should adopt a neutral position on change in the law on assisted dying.

The proposer Professor Raymond Tallis argued that the current situation was 'morally repugnant' and said that the BMA should adopt a policy of studied neutrality on the issue of assisted dying.

Speaking against, Dai Samuel said an 'act of kindness' could lead to 14 years in prison, and added that he was there to care for patients and could not countenance something that he considered akin to murder.

John McGough encouraged doctors to accept that some colleagues do support assisted dying.

Speaking against, medical student Rebecca Briscow said the medical profession cannot be excluded from the decision and that a position of neutrality would be a breach of patient trust. She warns that physician-assisted dying is cheap - and dangerous - and that doctors must be the safeguard.

Farah Jameel responded that keeping a patient alive isn’t always the right answer, and that there was no right or wrong answer for assisted dying. She said a position of neutrality was key.

Also speaking in support, Isky Gordon related an anecdote about a colleague - who went on to be exonerated by the GMC and police - being investigated for the treatment of a terminally ill and mentally competent patient.

Professor Baroness Illora Finlay said that the public would not understand why the BMA won't express a view on the prescription of potentially lethal drugs. 'The safeguards proposed are no more than a checklist.' She believed neutrality would tell parliament that the BMA saw this as acceptable.

Speaking for the motion, Tom Henderson admitted it was 'uncomfortable' to shift away from opposition to assisted dying. He says there were legal and accepted options for some people - those who could fly to Switzerland for example - but others were 'condemned' to suffer. He said neutrality would allow a balanced view of a complex argument.

Ethics Chairman Tony Calland argued that we must approach this with a logical head and not an emotional heart. If the law changed the medical profession would be involved so it was important that we stayed engaged in the debate.

BMA Chairman Hamish Meldrum said a position of neutrality would exclude doctors from the debate and urged the meeting to reject the motion.

In rejecting this move the BMA has sent out a strong message that doctors must play a leading role in this debate which could otherwise be far too easily swayed by celebrity endorsement and media outlets who have consistently acted as the cheerleaders for assisted suicide and euthanasia.

Majority medical opinion remains opposed to assisted dying and this vote is a victory for common sense. I hope that the BMA will now continue its valuable work in campaigning for high quality compassionate care for patients at the end of life.

Monday, 25 June 2012

This Wednesday, 27 June, the British Medical Association Annual Representative Meeting (ARM) will vote on a motion to go neutral on assisted suicide and euthanasia.

The BMA, the trade union for doctors, has been opposed to a change in the law for all but one year of its 180 year history.

But those proposing the motion will claim that this is an issue on which doctors are divided and where most members of the public favour a change in the law. Furthermore, they will argue that the British Medical Journal favours a neutral stance and that a poll published last week has shown that 62% of doctors agree.

The motion reads as follows:

* 332 Motion by THE AGENDA COMMITTEE (MOTION TO BE PROPOSED BY THE SHROPSHIRE DIVISION):
That this Meeting:-
i) believes that assisted dying is a matter for society and not for the medical profession;
ii) believes that the BMA should adopt a neutral position on change in the law on assisted dying.

So why not support it? Ten reasons:

1. If the BMA chooses to go neutral on this particular issue, it will be giving the issue a status that no other issue enjoys. Doctors, quite understandably, are strongly opinionated and also have a responsibility to lead. The BMA is a democratic body which takes clear positions on a whole variety of issues on the basis of a majority vote. This week the association will vote on issues as broadly ranging as Syria, torture, tobacco and the future of the NHS. Why should assisted suicide and euthanasia enjoy a position which no other issue shares, especially when doctors will actually be the ones carrying it out?

2. It will further damage doctors’ public profile. The industrial action over pensions has not been well received by all sections of the community, and however justifiable we regard it, it will not look good for doctors to take a strong position on their own financial interests but to have no position at all over whether doctors, to put it bluntly, should have the power, in some circumstances, to kill their patients.

3. This motion is part of a campaign led by a small pressure group with a particular political agenda. Healthcare Professionals for Assisted Dying (HPAD), which is strongly affiliated to the pressure group ‘Dignity in Dying’ (formerly the Voluntary Euthanasia Society) has 520 supporters, representing fewer than 0.25% of Britain’s 240,000 doctors. But they have flooded this year’s ARM with no less than nine motions calling for the association to go neutral. This is in line with HPAD’s and DID’s clearly stated campaign objectives to legalise ‘assisted dying’ and is aimed at neutralising medical opposition ahead of a new bill being introduced to parliament over the next year. DID is planning a mass lobby of parliament to support such a bill next week on 4 July. A neutral vote will be a vote for the success of this campaign.

4. The 62% support figure from DID/HPAD of doctors favouring a switch to neutrality is based on a questionable poll. Although widely trumpeted by the British Medical Journal, the poll was based on an unbalanced question which is currently the subject of a formal complaint to the Market Research Society. It was asked over a month ago without any clear definition of key terms such as ‘assisted dying’ and ‘terminally ill’ and was framed in an unbalanced way with a stem aimed at priming respondents. An on-line poll run last week by the BMJ after HPAD and DID had launched their campaign ran 82% against neutrality.

5. If the BMA goes neutral this week it will lead inevitably to a new attempt to change the law at parliamentary level over the next twelve months. In the only previous year in which the BMA took a neutral position (2005/6) we saw huge pressure to change the law by way of the Joffe Bill. Throughout that crucial debate, which had the potential of changing the shape of medicine in this country, the BMA was forced to remain silent and took no part in the debate. The same scenario would arise again. Doctors would have no collective voice.

6. The motion itself is broadly and vaguely worded. Were it to go through, this would not be simply a vote for ‘assisted suicide for mentally competent adults with less than twelve months to live’ as sought by DID and other campaigners. The motion simply talks about ‘assisted dying’, a term which is variously defined and which has no meaning in law. So it is not at all clear what doctors would actually be signing up to be neutral on. Does it include assisted suicide or euthanasia or both, and for which categories of patients?

7. The majority of doctors are opposed to a change in the law. Opinion polls show an average of 65% doctors opposing the legalisation of assisted suicide and/or euthanasia with the remainder undecided or in favour. Palliative Medicine Physicians are 95% opposed and the Royal Colleges of General Practitioners and Physicians (RCGP and RCP) are both opposed. Why choose to go neutral on an issue where there is such a strong majority amongst doctors?

8. Assisted suicide and euthanasia are contrary to all historic codes of medical ethics, including the Hippocratic Oath, the Declaration of Geneva, the International Code of Medical Ethics and the Statement of Marbella. Neutrality would be a quantum change for the profession and against the international tide.

9. To drop medical opposition to the legalisation of assisted suicide and euthanasia at a time of economic recession could be highly dangerous. Many families and the NHS itself are under huge financial strain and the pressure vulnerable people might face to end their lives so as not to be a financial (or emotional) burden on others is potentially immense.

10. Were the BMA To drop its opposition, and as a consequence a law were to be passed, it would leave the medical profession hugely divided at a time when, perhaps, more than any other time in British history, we need to be united as advocates for our patients and for the highest priorities in a struggling health service.

For the BMA to go neutral on assisted suicide and euthanasia would be inappropriate, undemocratic and potentially highly dangerous. It would also be playing into the hands of a small unrepresentative pressure group and giving an advantage to only one side of the debate. Furthermore it would communicate confused messages to the public at a critical time and divide the profession at a time when a united doctors’ voice is needed more than ever.

Friday, 22 June 2012

The Daily Mail and Daily Telegraph this week have run a story claiming that the NHS ‘kills off a 130,000 elderly patients every year’ through use of a ‘death pathway’.

The story has been picked up relatively uncritically by many news outlets around the world, and particularly pro-life sites (see here and here).

The claims are based on comments made by Professor Patrick Pullicino, who spoke at a Medical Ethics Alliance conference at the Royal Society of Medicine this week.

There are around 450,000 deaths in Britain each year of people who are in hospital or under NHS care. About 29% - 130,000 - are of patients who are on the Liverpool Care Pathway (LCP).

Professor Pullicino claimed that far too often elderly patients who could live longer are placed on the LCP and that has now become ‘assisted death pathway’ rather than a ‘care pathway’. He cited pressure on beds and difficulty with nursing confused or difficult to manage elderly patients as factors.

He also recounted how he had personally intervened to take a patient of the LCP who later went on to be successfully treated.

What do we make of all this? Are these national newspapers really revealing unprecedented levels of euthanasia in British hospitals or are these claims simply alarmist?

The Liverpool Care Pathway for the dying patient (LCP) is a treatment pathway used in the final days and hours of life which aims to help doctors and nurses provide effective end of life care.

It was initially developed between the Royal Liverpool Hospital and the City’s Marie Curie Hospice in the later 1990s and recommended to hospitals by the National Institute for Health and Clinical Excellence in 2004.

In 2006 a Health Department White Paper said it should be adopted across the country and it is now very widely used.

Before a patient can be placed on the pathway the multi professional team caring for them have to agree that all reversible causes for their condition have been considered and that they are in fact imminently dying.

The assessment then makes suggestions for palliative care options to consider and whether non- essential treatments and medications should be discontinued.

However it is by no means a ‘one way street’ and the patients on it are meant to be repeatedly assessed and taken off it if they show signs of improvement.

The programme provides suggestions for treatments to manage symptoms such as pain, agitation, respiratory tracts secretions, nausea and vomiting or shortness at breath that dying patients might experience.

The new version was an improvement on previous ones and made absolutely clear that patients must be imminently dying (ie. within hours or days of death) before being placed on the pathway.

The 2009 Telegraph story was criticised by the Association of Palliative Medicine and the Care Not Killing Alliance as inaccurate. The Times welcomed it as an attempt to address patients’ wishes and warned about alarmist press coverage.

The Department of Health has responded to these latest allegations by saying that ‘the Liverpool Care Pathway is not euthanasia and we do not recognise these figures’ and adds that the pathway has had overwhelming support from clinicians both at home and abroad including the Royal College of Physicians.

Patients should be monitored at least every four hours and if they improve they are taken off the pathway and given whatever treatment is best suited to their new needs. An audit of the pathway’s use in 2009 showed that ‘where the LCP is used people are receiving high quality clinical care for the last hours and days of life’. This audit reviewed end of life care in 155 hospitals and examined the records of about 4,000 patients.

What we are seeing this week is a classic application of the ‘post hoc propter hoc’ fallacy, the mistaken notion that simply because one thing happens after another the first event was a cause of the second event.

It is certainly true that 130,000 British patients per year are dying whilst on the LCP. But it does not therefore follow from this that the LCP is the cause of their deaths.

If a patient is judged to be imminently dying and is placed on the LCP and dies within hours or days one can be virtually certain that the death was caused by the underlying condition.

However, on the other hand, if a patient is placed on the pathway and has hydration and nutrition removed whilst being sedated and dies, say ten-fifteen days later, then there must be a very real question about whether the withdrawal of hydration actually contributed to the death. But to put a patient on the LCP for this length of time is quite inappropriate.

I have no doubt that there are some patients who are not imminently dying who are being placed on the LCP inappropriately in Britain as Professor Pullicino has alleged.

However this is not the fault with the pathway itself but rather relates to its inappropriate use. Any tool is only useful if it is used with the proper indications.

The overwhelming majority of people on the LCP are experiencing much better care at the end of life than they would have had if it had not been used.

So what lessons can we draw from his week’s story?

First, we need to be very wary of jumping to conclusions on the basis of alarmist headlines. Claims that huge numbers of people are being starved and dehydrated to death in Britain are not borne out by the facts.

Second, such claims run the risk of playing into the hands of the pro-euthanasia lobby who like to claim that doctors are killing thousands of British people with sedation, morphine and dehydration already and that legalising injection euthanasia will therefore change nothing.

Third, calling deaths on the LCP ‘euthanasia’ can also distract us from the very real threat of ongoing attempts to legalise assisted suicide and euthanasia. It can also undermine the public credibility of some of those who oppose euthanasia.

But finally, we also do need to be alert to doctors and other health care professionals, either through negligence, ignorance or perhaps even malicious intention, misusing a perfectly good care tool to speed the deaths of patients who are not imminently dying. That is why good audit and good supervision are so important. Any misuse of the LCP must be exposed and dealt with.

In good hands the LCP is a great clinical tool. But in the wrong hands, or used for the wrong patient, any tool can do more harm than good.

The immediate context is that members of DID and HPAD have flooded the BMA annual representative meeting next week with motions calling for the union to adopt a neutral position on ‘assisted dying’ ahead of a new bill being introduced into parliament.

The first three sentences of a press release the BMJ issued last week to this end read as follows:

‘The BMJ today supports a call for leading UK medical bodies to stop opposing assisted dying for terminally ill, mentally competent adults. Healthcare Professionals for Assisted Dying (HPAD), wants the BMA and royal colleges to move their position from opposition to neutrality. The call comes as a new poll commissioned by Dignity in Dying found that, of 1000 GPs, 62% support neutrality.’

I have already criticised Fiona Godlee on this blog and go into the polling question (and a related one) in much more detail there.

Letter to Sir Graeme Catto

Dear Sir Graeme,

I am writing to inform you that we have lodged an official complaint with the Market Research Society about a polling question which we believe may breach several Rules of the Market Research Society Code Guidelines.

The question below, which was given substantial coverage by the British Medical Journal in an Editorial last week, was posed by Dignity in Dying (DID) and Healthcare Professionals for Assisted Dying (HPAD), with the aim of moving the doctors’ union, the British Medical Association, to a neutral position on ‘assisted dying’.

A motion calling for the union to adopt a neutral position on ‘assisted dying’ is to be debated at the BMA ARM on Wednesday 27 June.

Detail of the question is outlined in a joint press release from DID and HPAD and in a copy of the poll results.

The poll was conducted by medeConnect Healthcare Insight (the research arm of Doctors.Net.UK) between 16 and 22 May 2012 who asked 1004 GPs an online question as follows:

‘Opinion polls indicate that doctors are divided on the issue of assisted dying for the terminally ill, with approximately 60% opposed to change. Do you agree or disagree that medical bodies (RCGP, BMA) should adopt a position of studied neutrality* on the issue of assisted dying for terminally ill, competent adults.*A position of studied neutrality indicates that a medical organisation is neither supportive of, nor opposed to a change in the law on assisted dying. A neutral position recognises and respects the diversity of personal and religious views of its members and their patients, and encourages open discussion.’

On 14 June the General Medical Council’s Investigation Committee reprimanded a Christian doctor who shared his faith with a patient at the end of a private consultation. They ruled that his actions ‘did not meet the standards required of a doctor’.

Dr Richard Scott (pictured) has now been issued with a warning which will remain on his record for five years. Further serious or persistent failure to follow GMC guidance will put (his) registration at risk.

Dr Scott, who has been a doctor for over 28 years, was initially investigated by the GMC after it received a complaint from a patient that he had discussed the benefits of Christianity with him.

The full judgement is available on the GMC website and the Huffington Post gives more detail of what Dr Scott said in his defence.

The case arose from a complaint made to the GMC on 14 August 2010 by a patient’s mother about the doctor’s conduct when her son consulted him ten days earlier. It was alleged that Dr Scott ‘abused his position as a medical practitioner to push (his) religion upon a vulnerable patient’.

The patient on 20 October 2010 provided a written statement on which the GMC’s allegations were based. After seeking Dr Scott’s views on the allegations, which he did not accept, they sought to issue him with a warning, which he refused thus exercising his right to an oral hearing before the investigation committee.

When the patient refused to give evidence to the committee last autumn the case was adjourned until June 2012. On this occasion the patient again refused to appear but eventually agreed to give oral evidence over the phone.

During the hearing the committee noted that there was ‘clearly a conflict of recollection of what occurred in the consultation between the participants’ but considered that ‘both witnesses were honest and not trying to deceive’.

Dr Scott insisted that he had acted with the GMC guidance but also accepted that if he ‘had acted in the way in which the alleged this would be a significant departure from (it)’.

There was, in other words, a significant disagreement between Dr Scott and the patient about what was actually said during the consultation.

The committee, however, considered that the patient ‘gave credible evidence, direct answers and made all due allowances’ in Dr Scott’s favour. But they considered that ‘a number’ of Dr Scott’s responses ‘were in conflict with the evidence’ and that at times he ‘appeared to be evasive when answering questions’.

In other words the committee appeared to prefer the patient’s evidence over that of Dr Scott where their recollections were in conflict.

However, whilst a number of the allegations made were found ‘proved’, three significantly were not, raising questions about the accuracy of some of the patient’s evidence.

In summary, the committee concluded that Dr Scott ‘caused the patient distress which (he) should have foreseen’ by the way he expressed his beliefs. He also ‘sought to suggest (his) own faith had more to offer than that of the patient’ and in so doing ‘sought to impose his own beliefs’.

The GMC claimed that Dr Scott’s actions were in direct conflict with paragraph 19 of its supplementary guidance: Personal Beliefs and Medical Practice’:

‘You must not impose your beliefs on patients, or cause distress by the inappropriate or insensitive expression of religious, political or other beliefs or views’.

and also with Paragraph 33 of ‘Good Medical Practice’:

‘You must not express to your patients your personal beliefs including political, religious or moral beliefs, in ways that exploit their vulnerability or that are likely to cause them distress.’

The GMC defended its issuing of a warning by saying it was obliged ‘to lay down a marker as to expected standards and to maintain public confidence in the profession’. It also said that ‘the discussion of religion within consultations is not prohibited’ and that this case ‘relates to the manner in which religion was approached during the consultation’.

The case raises a number of important questions for Christian doctors:

1.Is the GMC guidance overly restrictive?

The GMC Guidance, ‘Personal Beliefs and Medical Practice’ is currently under review but the 2008 version, under which Dr Scott has been assessed ‘attempts to balance doctors' and patients' rights - including the right to freedom of thought, conscience and religion, and the entitlement to care and treatment to meet clinical needs - and advises on what to do when those rights conflict.’

It does not intend to ‘impose unnecessary restrictions on doctors’ but does point out that doctors have an obligation not to impose their beliefs on patients. So there is no blanket prohibition on expressing personal beliefs, as long as it is done in a way that is sensitive and appropriate.

The guidance also underlines the principle that doctors must ‘make the care of (their) patient (their) first concern’ and must treat them ‘with respect, whatever their life choices and beliefs’.

These are all good principles that I personally have no problem with. No doctor, Christian or otherwise, should impose his views on his patient or seek to exploit his or her position.

However, the guidance goes on to stress that all patients and doctors have personal beliefs implying that these principles apply not just to those who subscribe to a particular faith, but to everyone.

‘Personal beliefs and values, and cultural and religious practices are central to the lives of doctors and patients.’ ‘All doctors have personal beliefs which affect their day-to-day practice.’

It also emphasises that taking account of patients’ beliefs is part of good medical care.

‘Patients' personal beliefs may be fundamental to their sense of well-being and could help them to cope with pain or other negative aspects of illness or treatment.’ ‘For some patients, acknowledging their beliefs or religious practices may be an important aspect of a holistic approach to their care. Discussing personal beliefs may, when approached sensitively, help you to work in partnership with patients to address their particular treatment needs.’

Provided these guidelines are retained within the new guidance, they are parameters that Christian doctors should be able to work with.

2.Was this investigation fair?

The faith conversation which seems to have got Richard Scott into trouble came at the end of a 20 minute consultation, when he asked the patient whether he could talk about his Christian faith and the patient replied ‘Go for it’. So there was mutual consent and when the conversation became tense they stopped it.

The key problem faced by the GMC was that they were making an assessment based on two varying accounts of what actually happened, one from the patient and one from Dr Scott. However, in so doing they seem to have preferred the patient’s testimony over that of Dr Scott where the two accounts conflicted. Also the initial complaint was made by the patient’s mother who was not a witness to the consultation and transcripts of Dr Scott’s radio interviews were actually gathered by the National Secular Society, who undoubtedly had an ideological vested interest in the case.

Furthermore there were elements of the patient’s written testimony which were not upheld on cross-examination and he repeatedly refused to turn up to give evidence face to face. The Christian Legal Centre, who represented Dr Scott, have understandably raised questions about the legality and transparency of this process and had undertook unsuccessfully to have the case ‘struck out’. They are still considering whether to ask for a judicial review of the way the GMC conducted the enquiry.

Given, as acknowledged by the GMC, that Dr Scott had a previously unblemished record and was able to produce many patients’ testimonials, might they not have given him the benefit of the doubt in these particular circumstances? Wasn’t this a case that would have been better resolved locally with a mutual apology and a handshake? Has the GMC overreacted?

Furthermore, might the judgement encourage other individuals or organisations to bring forward vexatious written complaints against other Christian doctors knowing that it will essentially be the patient’s word against the doctor’s?

And why should suggestions that faith might help a patient be treated any differently from suggestions about other lifestyle choices or beliefs? As one doctor has argued in Pulse this week:

‘Patients already could say that you are ‘exploiting their vulnerability’ and ‘causing them distress’ when you speak to them about lifestyle choices which have led to obesity or addiction, but that is OK, because the evidence shows that dealing with these things would be good for them. Dr Scott has presented similarly robust evidence that shows that ‘doing God is good for your health’. So why would the GMC want to encourage one and discourage the other?'

There are certainly questions here that are worth asking and I am aware that a number of Christian doctors have already written to the GMC about them. Others who wish to express concern about the case, or to ask questions, can do so via the GMC website. The most appropriate addressee would be Niall Dickson, the Chief Executive.

3.What sort of faith discussions are still allowed within a consultation?

‘The first point is that the start of a consultation is not the point at which you start introducing your faith and you should be where the patient is at. But there may be circumstances where a patient is at a point where they do want to discuss faith and it may be appropriate for the doctor to reflect on their own faith during that discussion.’

When asked how the GMC determined whether or not a doctor had expressed ‘religious, political or other beliefs or views’ in an ‘inappropriate or insensitive’ way Dickson explained that the GMC guidance was there to enable doctors to make good judgements themselves:

‘I am not there to judge, the doctor is there to judge and this essence of medicine is making judgements in the face of uncertainty and the importance of the doctor understanding where the patient is at. Taking a vulnerable patient and imposing your religious views on them and exploiting their vulnerability would be on the wrong side of the line as far as we are concerned.’

Jane O'Brien, GMC Assistant Director for Standards and Fitness to Practise, in a letter to the Daily Telegraph in 2009 even suggested that a ‘tactful' offer to pray could be appropriate. O’Brien’s letter in full read as follows:

‘Nothing in the GMC's guidance Personal Beliefs and Medical Practice (2008) precludes doctors from praying with their patients. It says that the focus must be on a patient's needs and wishes. Any offer to pray should follow on from a discussion which establishes that the patient might be receptive. It must be tactful, so that the patient can decline without embarrassment – because, while some may welcome the suggestion, others may regard it as inappropriate.’

The same sentiments were expressed in a letter from David Horkin, GMC Investigation Officer, to a CMF member this last week.

‘The GMC has no objections whatsoever to the clinician bringing up faith in the consultation if it is done in an appropriate and sensitive manner. The patient must of course consent and be happy for such discussions to take place. Also, the clinician should take note of the patient's own beliefs and not attempt to belittle / disrespect their own faith or lack thereof. You should not attempt to impose your views on any patient who does not want to discuss such matters.’

These three statements strongly endorse the appropriateness of sensitive faith discussions.

4.Are doctors still free to practise ‘spiritual care’

Taking all this into account, it is clear by the GMC’s own admission that doctors are fully entitled to take part in ‘faith discussions’ within a medical consultation provided that they are carried out in an atmosphere of sensitivity, permission and respect.

In fact, good doctors, we might argue, have a professional duty to practise ‘whole person’ medicine that is not concerned solely with physical needs, but also addresses social, psychological, behavioural and spiritual factors that may be contributing to a person’s illness.

It would be a tragedy if, as a result of this case, Christian doctors shrunk back from providing appropriate spiritual care or from sharing their own Christian beliefs in a sensitive way, when it was appropriate, and when the patient had welcomed it.

Wednesday, 20 June 2012

Few people in Britain now raise an eyebrow over the issue of abortion and I was struck by two casual references to it this week in relation to euthanasia.

BMJ Editor, Fiona Godlee, in her controversial article calling for the BMA and other medical bodies to go neutral on ‘assisted dying’ said that doctors were at the same stage with euthanasia that they were with abortion in the 1960s.

The clear implication was that euthanasia, like abortion, would eventually become acceptable to the medical profession and be legalised.

What she didn’t say was that abortion was legalised on the basis that it would only apply to a few extreme cases. But now the medical profession carries out over 200,000 abortions a year in England, Wales and Scotland.

Then there was Jane Nicklinson, wife of Tony Nicklinson, the man with locked-in syndrome who is this week seeking the permission of the High Court for a doctor to end his life with a lethal injection.

In a Channel Four Dispatches Programme screened on Monday night she said that people now accepted abortion but that there would always be a small minority who objected. Her implication was that euthanasia should be viewed in the same way.

There are 42 million abortions carried out now worldwide, with the largest numbers in India and China as a result both of their large populations and the widespread practice of ‘sex selection’ – selectively aborting female babies. 200,000 abortions a year take place in Britain.

Virtually all these abortions are carried out by doctors, although abortion is against the Hippocratic Oath, against the Declaration of Geneva and against the International Code of Medical Ethics. In fact in 1947 the British Medical Association even called abortion 'the greatest crime'. So why this change in attitude?

Abortion is now so commonplace that few stories about it now have the capacity to shock but there have been some revelations this year, which have made even the hardest pro-choice activists draw breath.

The first involved a photo widely circulated on the internet showing a baby whose mother was forced to have an abortion in China.

Feng Jiamei, from Shaanxi province, was made to undergo the procedure in the seventh month of pregnancy. Ms Feng was forced into the abortion as she could not pay the fine for having a second child, US-based activists said.

Her husband said his wife had been forcibly taken to hospital and restrained before the procedure. The BBC's Jon Sudworth in Shanghai says such allegations are nothing new in China, but what has made this one different is a widely circulated photo of the woman lying next to the baby's corpse.

Chinese officials have now apologised to her and the Ankang city government said it decided to suspend three officials in Zhenping county following initial investigations.

Life Site News this week reports on two abortion practitioners who, it is alleged, fed the bodies of girl babies killed in abortions to dogs to hide the fact that they were carrying out sex-selection abortions.

The husband and wife doctor team have been charged with homicide after a woman died but no charges have been laid about the disposal of the babies’ bodies.

Then there is the report of 17,000 ‘Aphrodisiac’ pills made from dead, aborted babies being seized by police in South Korea.

According to Lifesite News the pills originate in China, where manufacturers reportedly obtain the corpses of aborted or stillborn babies from hospitals and abortion facilities, then dehydrate their bodies before crushing them up.

They are sold as sexual stamina enhancers and as alternative medicine for a variety of ailments.

Similar allegations regarding the use of human fetuses in China have emerged in the past, including claims that some restaurants in China have served ‘fetal soup,’ and that Chinese beauty product manufacturers have included fetal materials in their products.

Stories like this get wide coverage understandably. But why does it take abuses this extreme now to prick our consciences on abortion?

Monday, 18 June 2012

Tony Nicklinson is 58 and paralysed from the neck down after suffering a stroke in 2005. He is seeking legal permission for a doctor actively to end his life.

A Channel 4 Dispatches programme tonight,'Let our dad die', put Tony’s case with powerful emotion but it did not tell us that most people with locked-in syndrome do not actually think like this man.

No one can help but be sympathetic to Tony Nicklinson but cases like his are extremely rare and hard cases make bad law.

The overwhelming majority of people with severe disability - even with ‘locked-in syndrome’ - do not wish to die but rather want support to live and the longer people have locked-in syndrome then generally the better they learn to cope with it and find meaning, purpose and contentment within the confines of the condition.

So he communicates with his eyes: looking up means yes, down means no, cross-eyed means don't know. He chooses letters and words by blinking at them on a screen, which his computer translates into the written and spoken word.

This allows him to easily respond to questions from his small army of committed carers about what he wants and how he feels and also to work as a DJ.

Not surprisingly the playlist for his Eye Life radio show takes weeks to put together but he still does it!

Martin Pistorius is a South African man who ended up paralysed and comatose following a throat infection at the age of 12. His awareness began to improve four years later and by the age of 19 had fully returned.

However it was a further five years before a therapist noticed that he was trying to communicate. The penny eventually dropped that he had been aware of everything going on around him for almost ten years whilst everybody had assumed he was unconscious.

Now, ten years later aged 36, he is married and runs a computer business despite being still in a wheel chair with limited limb movement and using computerised speech.

Nikki Kenward was left disabled after a partial recovery from paralysis caused by Gullain Barre syndrome. Her own inspiring personal story is well worth a read. Now she campaigns telling people about the dangers that changing the law to allow assisted suicide or euthanasia would pose to those with serious disability.

Then there is Graham Miles, the pensioner who told how he beat ‘locked in syndrome’ after suffering a massive stroke.

But perhaps the most famous of all is Jean-Dominique Bauby, the French editor of Elle magazine, who suffered a severe stroke, from which he never recovered, and yet wrote, the autobiographical ‘Diving Bell and the Butterfly’ which was ‘dictated’ letter by letter and has been made into a major feature film.

Most people with locked-in syndrome are happy, according to the biggest survey of people with the condition.

The desire to die is not primarily about physical symptoms but about the particular person and their ability to adapt to living with a profound disability.

Much as we sympathise with Tony Nicklinson, we should not, as RCGP President Iona Heath argued recently, be seeking technical solutions like euthanasia to what is in reality an existential problem.

Tony Nicklinson is 58 and paralysed from the neck down after suffering a stroke in 2005.

He is seeking legal permission for a doctor actively to end his life.

The Ministry of Justice had previously argued that the case should be struck out on the grounds that it is a matter for parliament, rather than the courts, to decide.

However the case has been allowed to go forward to a High Court hearing (A second case (that of ‘AM’ or ‘Martin’) is to be heard at the same time but has attracted less publicity).

The key point to grasp about this case is that Nicklinson, because he is not capable of killing himself even with assistance, is not seeking assisted suicide but euthanasia. So this is an assault on the law of murder and not the Suicide Act 1961.

Nicklinson is pushing for an even greater change in the law than either the controversial Falconer Commission on ‘Assisted Dying’ or the lobby group Dignity in Dying (formerly the Voluntary Euthanasia Society). They campaign for assisted suicide for people who are terminally ill – but euthanasia is one step further than assisted suicide and Nicklinson is not terminally ill.

Such a change would have far reaching implications by potentially removing legal protection from large numbers of sick and disabled people.

No one can help but be sympathetic to Tony Nicklinson but cases like his are extremely rare and hard cases make bad law. The overwhelming majority of people with severe disability - even with ‘locked-in syndrome’ - do not wish to die but rather want support to live and the longer people have locked-in syndrome then generally the better they learn to cope with it and find meaning, purpose and contentment within the confines of the condition (See my previous blogs about Bram Harrison, Nikki Kenward, Jean-Dominique Bauby, Martin Pistorius and Matt Hampson)

The desire to die is not primarily about physical symptoms but about the particular person and their ability to adapt to living with a profound disability. Most people with locked-in syndrome are happy, according to the biggest survey of people with the condition. We should not, as RCGP President Iona Heath argued recently, be seeking technical solutions to what is in reality an existential problem.

Nicklinson's legal team will be arguing two things:

1.'Necessity' can, in these circumstances, be a defence to murder (see my previous blog for what this means)

2. The existing law of murder, insofar as it denies Nicklinson the chance to be actively killed at his request, is incompatible with Article 8 of the ECHR (European Convention of Human Rights) - dealing with 'right to respect for private and family life'.

Nicklinson has the right to refuse treatment under existing law, and could do so, but what he is seeking to do instead is to give doctors the power to kill in specific circumstances on grounds of ‘necessity’. That would be a very dangerous precedent indeed.

The current law is clear and right and does not need fixing or further weakening. On the one hand the penalties it holds in reserve act as a powerful deterrent to exploitation and abuse by those who might have an interest, financial or otherwise, in the deaths of vulnerable people. On the other hand the law gives judges some discretion to temper justice with mercy when sentencing in hard cases. We should not be meddling with it.

Any further removal of legal protection by creating exceptions for bringing prosecutions would encourage unscrupulous people to take liberties and would place more vulnerable people – those who are elderly, disabled, sick or depressed – under pressure to end their lives so as not impose a burden on family, carers or society.

Even in a free democratic society there are limits to choice. Every law limits choice and stops some people doing what they might desperately wish to do but this is necessary in order to maintain protection for others. No man is an island and this case is about much more than Tony Nicklinson.

Sunday, 17 June 2012

A common argument from the pro-choice lobby is that legalising abortion in 1968 saved thousands of women who would have otherwise died from back-street abortions.

Before 1968, it is contended, women with unwanted pregnancies who did not want to have their babies had no choice but to seek the help of amateur ‘back-street’ abortionists who carried out their procedures with coat-hangers or other similarly inappropriate ‘instruments’. The result was that women often developed infections and died.

Once abortion was legalised in 1968 women could then obtain abortions that were not only ‘legal’ but also safe.

The argument is that any move to restrict abortion now would drive women back into the hands of backstreet abortionists leading again to thousands of deaths.

The reality is much more complex than that. But you have to look at the actual evidence to understand what really happened.

First, maternal mortality from all causes, including abortion fell dramatically long before abortion was legalised as a result of better medical care.

Second, many so called ‘back-street abortions were actually carried out ‘illegally’ by ‘skilled professional’ nurses and doctors using surgical instruments in sterile conditions.

Third, legalising abortion did not eliminate all maternal deaths, as some women now began to die of legal abortions, and in addition there was still a trickle of illegal abortions.

However since 1968 all abortion deaths in Britain have fallen to almost zero.

The two slides I have used in this blog have been taken from a presentation on maternal mortality by Professor Owen Drife of the University of Leeds and can be viewed online.

The first slide (above)shows the dramatic drop in maternal deaths from all causes that happened long before the legalisation of abortion in 1968. This fall was clearly not due to legalising abortion.

The second slide (left) shows deaths from legal abortion, illegal abortion and miscarriage since 1952 (the first slide starts at 1935 so this second slide covers only the last part of this period after rates had already fallen dramatically).

In the years 1952-4 there were just over 50 women dying per million maternities from illegal abortion. As there were far less than a million maternities per year in 1952 (there are only 700,000 births a year now) this means that the actual number of women dying from abortion per year would have been even less than 50.

In the three years around legalisation (1967-1969) this had fallen to 30 deaths per million maternities but we were also starting to see deaths from legal abortions.

In the three years after this (1970-1972) the death rate from illegal abortions was about 15 per million maternities falling to 5 per million maternities in 1973-1975.

But the striking point through this six year period is that as many women were dying from legal abortions as from illegal abortions.

From 1976 on deaths from both legal and illegal abortions fell to almost negligible levels. But in each case this was due not to the legalisation of abortion but to improving standards of medical care.

A similar pattern has been observed in all developed countries. US statistics can also be viewed online.

The chart shown was used on the floor of the US Senate during the tumultuous debate on abortion in 1981. It was compiled from official US statistics and was not challenged by the pro-abortion lobbyists.

The early sharp drop occurred largely because penicillin became available. Note that after Penicillin became available to control infections, the number of deaths stabilized during the 1950s at about 250/year but by 1966, with abortion still illegal in all states, the number of deaths had dropped steadily to half that number.

In 1973 there should have been a sharp drop in women dying as abortion was made legal that year following the Roe vs Wade Supreme Court judgement. The chart, however, shows that there was no such drop.

The line didn’t even blip. The previous rate of decline actually slowed, to flatten out in the late 70s and 80s. According to the US statistics legalisation of abortion hardly saved any women’s lives at all.

But of course what legalised abortion did do throughout the Western world was to increase dramatically the number of babies being aborted.

There are now 1.3 million abortions a year in the US and over 200,000 a year in the UK. But these are only a fraction of the total of 42 million carried out annually.

There was nothing surprising about this. The BMJ’s record of editorial bias on euthanasia and assisted suicide has been noted before and the deputy editor Tony Delamothe, who has previously written passionately on the subject is a named supporter of the pressure group ‘Healthcare Professionals for Assisted Dying’ (HPAD).

HPAD were responsible for penning two of this week’s articles. Not bad coverage for a group representing fewer than 0.25% of Britain’s 240,000 doctors!

One of these was a comment piece from Ray Tallis, HPAD chairman, which called for the BMA and Royal Medical Colleges to take a position of ‘studied neutrality’ on ‘assisted dying’.

The second was an emotive plea for a change in the law from the daughter of HPAD’s founder who died of pancreatic cancer.

The significance of this move is that the British Medical Association is about to debate a motion calling for the doctors’ trade union to take a neutral position on the issue. HPAD, which operates under the auspices of Dignity in Dying, the former Voluntary Euthanasia Society, flooded the BMA this year with no less than nine almost identical motions calling for neutrality.

In other words, this is all part of a carefully orchestrated campaign.

Godlee and Delamothe are of course entitled to their individual opinions, provided of course that they remain transparent about their ideological vested interests.

But we do expect Britain’s highest circulation medical journal, which many regard as the mouthpiece of the medical profession in Britain, to deal with controversial subjects in an even-handed and evidence-based way.

Earlier this week the BMJ issued a press release about the articles in an attempt to bring them to international attention. I was asked to comment at the time and was interested to see how it presented the story.

The press release bore the provocative title, ‘BMJ supports call for medical bodies to stop opposing assisted dying’ and the first three paragraphs read as follows:

‘The BMJ today supports a call for leading UK medical bodies to stop opposing assisted dying for terminally ill, mentally competent adults. Healthcare Professionals for Assisted Dying (HPAD), wants the BMA and royal colleges to move their position from opposition to neutrality. The call comes as a new poll commissioned by Dignity in Dying found that, of 1000 GPs, 62% support neutrality.’

I thought that the prominence given in the press release to the BMJ’s call for neutrality and the 62% figure were particularly telling, given that in Godlee’s editorial they featured only in the very final paragraph.

Clearly the BMJ, and Godlee as editor, wanted to give the call and the survey a huge level of publicity.

According to the BMJ Godlee qualified as a doctor in 1985 and in 1994 spent a year at Harvard University as a Harkness Fellow, evaluating efforts to bridge the gap between medical research and practice.

On returning to the UK, she led the development of BMJ Clinical Evidence, which evaluates the best available evidence on the benefits and harms of treatments and is now provided worldwide to over a million clinicians in 9 languages.

So she is a person who is both well qualified to judge evidence and also a stickler for claims in peer-reviewed journals being soundly evidence-based.

So I was most interested to see the strength of the evidence for this 62% figure. This was referenced in footnote 17 of her article, but this footnote merely provided a link to the HPAD website events page.

I wonder whether Godlee herself had seen these before she wrote her article (and if so why she did not link to them directly) or whether she simply took HPAD’s say so (through ‘personal communication’?) as unadulterated truth. My guess is that we might never know.

As it turned out the poll was conducted by medeConnect Healthcare Insight (the research arm of Doctors.Net.UK) between 16 and 22 May 2012 who asked 1004 GPs an online question.

So what was the question DID actually asked which elicited this 62% response? You have to go to the 2nd footnote of the press release to find out but it read as follows:

‘Opinion polls indicate that doctors are divided on the issue of assisted dying for the terminally ill, with approximately 60% opposed to change. Do you agree or disagree that medical bodies (RCGP, BMA) should adopt a position of studied neutrality* on the issue of assisted dying for terminally ill, competent adults.*A position of studied neutrality indicates that a medical organisation is neither supportive of, nor opposed to a change in the law on assisted dying. A neutral position recognises and respects the diversity of personal and religious views of its members and their patients, and encourages open discussion.’

Of course, the value of polls such as this depends both on the reputability of the polling agency (and medeConnect is highly regarded) and also on the quality of the question.

Some observations:

1.The term ‘assisted dying’ is not defined in the question and has no meaning in law. It was actually a term invented by the pro-euthanasia lobby and is generally used as a euphemism for both euthanasia and assisted suicide. However different groups define it in very different ways. But what did the respondents actually understand by it?

2.‘Terminally ill’ is similarly a term with a range of meaning to different people. DID define it as having less than twelve months to live, although they are unclear if this means with or without treatment. This is the definition they will be using when they use these figures to campaign, but is this what the respondents will have understood?

3.The clear intent of DID and HPAD was to use this figure to campaign for the BMA to take a neutral position on ‘assisted dying’ in order to neutralise opposition for a new private member’s bill in parliament during the next year. Might respondents have voted differently if they had known this? I wonder.

4.The question states that about ‘60% of doctors are opposed to change’ but does not say what change. If this was meant to mean ‘opposed to a change in the law to allow assisted suicide and euthanasia to be legalised’ then why did it not say so? And where did the ‘60%’ figure come from given that Godlee herself quotes the 2009 Seale study’s figure of 65%.

5.The most important question from a pollster’s point of view, however, is why DID chose to insert the information they did in the first sentence of the question. Because the giving of this information, that seems to have been intended to influence the result, thereby makes this group not representative of all GPs who might be asked. The context has changed. In short, this group has been primed.

Pollsters know that the way a question is asked can have a strong bearing on the responses received. That is why there are strict codes about the phrasing of questions. It will be interesting to see if this question actually breaches the national research society code.

But to labour the point let me illustrate how the introductory sentence in the question might have been worded in other ways that may have achieved a different result:

'Opinion polls indicate that 95% of specialists in palliative medicine are opposed to a change in the law to allow assisted suicide or euthanasia for terminally ill patients. Do you agree or disagree that medical bodies (RCGP, BMA) should adopt a position of studied neutrality* on the issue of assisted dying for terminally ill, competent adults.'

Or perhaps:

'A small group of doctors called HPAD, representing less 0.25% of all doctors in the UK and closely affiliated to the former voluntary euthanasia society, is intending to introduce a motion to the BMA annual meeting in order to move the BMA to a neutral position on assisted dying, thereby neutralising medical opposition to a new private members bill to be introduced very soon. Do you agree or disagree that medical bodies (RCGP, BMA) should adopt a position of studied neutrality* on the issue of assisted dying for terminally ill, competent adults.'

I was interested to see that Godlee had also quoted another study from DID to support the following statement in her article.

‘When asked in a poll on doctors.net whether they would want the option of assisted dying for themselves, a third of the 1000 general practitioners surveyed said they would, a third said they would not, and the remainder were unsure’

The reference again was to a webpage, interestingly this time on DID’s website.

This time background information about the question on the site was not available so I emailed DID for a copy of the poll itself (I wonder if Godlee went this far or simply gave the web reference possibly supplied to her by HPAD/DID? ) To DID’s credit they sent the information to me within the hour.

The question read as follows:

‘If you were terminally ill and suffering unbearably at the end of life with only months or weeks to live, and palliative care options had been explored, would you personally want the choice of legalised medical help to die so you could control the time of your death?’

Well that is not how Godlee has presented it, but then I am assuming that she did not actually read the question. It is noteworthy that only 33% of 1,001 GPs said yes to a question worded this way but it demonstrates powerfully the strong opposition there is to a change in the law within the medical profession at large.

Is Godlee just being sloppy in her use of this data? Or does she have an agenda that she is pursuing with such passion that she has inadvertently let her usual high standards for seeking strong evidence slip?

As someone who helps pay her salary through my BMA subscription, I would like to know. I suspect I am not alone in this.

A High Court judge ruled yesterday that it is in the best interests of a woman who suffers from ‘extremely severe’ anorexia to be fed against her wishes.

Mr Justice Peter Jackson found that the 32-year-old former medical student, who has other chronic health conditions, ‘lacked capacity’ to make a decision about life-sustaining treatment (full judgement here).

Sitting at the Court of Protection in London, the judge said it was a ‘very difficult decision’ to make in a situation requiring ‘a balance to be struck between the weight objectively to be given to life on one hand and to personal independence on the other’.

Her case had ‘raised for the first time in my experience the real possibility of life-sustaining treatment not being in the best interests of a person who, while lacking capacity, is fully aware of her situation’.

Giving his conclusion in a judgment made public, he said: ‘The competing factors are, in my judgment, almost exactly in equilibrium, but having considered them as carefully as I am able, I find that the balance tips slowly but unmistakably in the direction of life-preserving treatment. In the end the presumption in favour of the preservation of life is not displaced.’

He declared that ‘it is lawful and in her best interests for her to be fed, forcibly if necessary’ and added that the ‘resulting interference’ with her rights was ‘proportionate and necessary in order to protect her right to life’.

He added, ‘We only live once - we are born once and we die once - and the difference between life and death is the biggest difference we know. E is a special person, whose life is of value. She does not see it that way now, but she may in future. I would not overrule her wishes if further treatment was futile, but it is not. Although extremely burdensome to E, there is a possibility that it will succeed.’

This judgement will no doubt be controversial as it raises questions of what the term ‘best interests’ means when applied to patients who lack mental capacity. But I believe the decision was the right one.

‘We welcome this ruling. The judge has made a wise and courageous decision in favour of life in this difficult and distressing case. In so doing he has emphasised that all human life is deserving of profound respect and strong protection and also that acting in the best interests of people who are lacking capacity does not always mean acceding to their demands. We do not always know what is best for us and to have abandoned this vulnerable woman at her point of greatest need would have been the wrong option. Where there is life there is still hope and by continuing with care and support there still remains the possibility that she may come to value her life and eventually respond to treatment for her severe anorexia. ‘

The unnamed patient, from Wales, was described as a highly talented and intelligent woman who held ambitions of having a family and becoming a doctor before she became seriously ill in her mid-twenties.

She had twice signed forms last year saying she did not want to be given treatment to keep her alive and had told the judge that she felt her life was ‘pure torment’ and that all her efforts to recover had failed.

The woman’s illness dates back to her childhood. She suffered serious sexual abuse between the ages of four and 11, unknown to her parents. At 12 or 13 she began binge eating and forcing herself to vomit, and started to drink alcohol.

When she was 15 she was admitted to a specialist adolescent eating disorder unit, and later began a medical degree. However, she began drinking heavily after a bad relationship and dropped out of university. Between 2006 and 2010, she spent more than half of her time in specialist units for eating disorders or alcoholism.

The authorities made an urgent application to the court last month because the woman was refusing to eat and it was believed her death was imminent.

I’m sure that many people will be praying for this poor woman in the hope that her treatment will be successful.

Friday, 15 June 2012

Older people are today being warned not to fall prey to bogus retail and investment schemes, after 78 rogue companies raking in more than £28 million from people were shut down in the last three years alone.

The companies scammed almost 2,000 investors between them and the oldest victim was aged 92, according to the Insolvency Service, which wound the firms up.

Issuing their warning on World Elder Abuse Awareness Day, campaigners said these scams often use high-pressure tactics or sell products at grossly inflated prices and conmen would cold call older people and refuse to hang up until they have closed a sale.

You probably won’t hear about it from any UK media outlet but the World Health Organisation produced a fact sheet.

Until the advent of initiatives to address child abuse and domestic violence in the last quarter of the 20th century, abuse of the elderly remained a private matter, well hidden from public view.

Today, it is increasingly being seen as an important problem and one that is likely to grow as many countries experience rapidly ageing populations. It is predicted that by the year 2025, the global population of those aged 60 years and older will more than double, from 542 million in 1995 to about 1.2 billion.

A number of situations appear to put the elderly at risk of violence. In some cases, strained family relationships may worsen as a result of stress and frustration as the older person becomes more dependent. In others, a caregiver’s dependence on an older person for accommodation or financial support may be a source of conflict.

Elder abuse takes place in many different settings – for example, the older person’s home, care homes, nursing homes and hospitals. It happens when an older person’s human rights and dignity are violated. It can come through financial scams (as above), physical attacks, sexual abuse, psychological abuse or neglect. The perpetrators are often in a position of trust and have control of the life of the older person.

Elder abuse can also include actions that many people might not consider. For example, physical abuse can include inappropriate use of medication or force feeding, emotional abuse can include treating an older adult like a baby or otherwise injuring his or her dignity, and sexual abuse includes any sexual contact with a person who is incapable of consenting.

Furthermore, older adults are particularly vulnerable to less common forms of abuse, such as neglect and abandonment, violations of rights to privacy, community support and information, and financial abuse, which is the most prevalent form of abuse among older adults.

Financial abuse is ‘the illegal or improper use of an incapacitated or vulnerable adult or his resources for another’s profit or advantage.’

This type of exploitation can take many forms such as forgery, misappropriation of cash or assets, abuse of joint accounts, or abuse of power of attorney. Signs of financial exploitation may include disparity between income and assets, unexplained or sudden inability to pay bills, inaccurate or no knowledge of finances, fear or anxiety when discussing finances, or unprecedented transfer of assets to others.

Financial exploitation of a vulnerable adult can occur without the elder’s knowledge, by trickery, intimidation, or coercion, or when the elder is too confused to give informed consent.

A slight majority of financial exploitation victims are elderly females over age 70 who live alone. They may also suffer from one or more physical or mental impairments. Perpetrators are most often relatives of the victim, typically the adult children.

Nationwide financial exploitation is the third most frequent form of abuse after neglect and emotional abuse. Estimates are that 30-40% of elder abuse involves some form of financial exploitation.

It is often argued that legalising euthanasia or assisted suicide would be a recipe for elder abuse. Given the vulnerability of many older people, who already feel themselves to be a financial, emotional or care burden on others, this is a powerful reason for not changing the law and needs to be borne in mind over the next few weeks as the pro-euthanasia lobby piles on pressure aimed at changing the law.

There are too many people already who have an interest, financial or otherwise, in an older person’s death. Let’s not give them any encouragement. And let’s work to honour, protect and uphold the older members of our community.

The Bible insists that we respect and honour old people (Leviticus 19:32; Proverbs 20:29) carry their burdens; listen to their advice (Proverbs 23:22-23; Job 32:6-9) and serve them as we would serve the Lord himself.

Wednesday, 13 June 2012

The British Medical Journal this week contains three articles aimed at neutralising medical opposition to euthanasia.

The BMJ, which remains editorially independent from the British Medical Association, but is sent to all members, has a long track record of backing liberal causes, amongst them the legalisation of assisted suicide and euthanasia.

A comment piece from Ray Tallis (pictured), chairman of the pressure group ‘Healthcare Professionals for Assisted Dying’ (HPAD) calls for the BMA and Royal Medical Colleges to take a position of ‘studied neutrality’ on euthanasia.

An emotive ‘personal view’ by Tess McPherson, relates the story of the death of her mother Ann, an Oxfordshire GP who died from cancer of the pancreas last year and was the founder of HPAD.

Godlee acknowledges in her editorial that 65% of doctors are opposed to a change in the law but makes much of a ‘poll of 1,000 GPs’ commissioned by the pressure group Dignity in Dying last year which allegedly showed that ‘62% supported neutrality’.

The poll is referenced to the HPAD website events page but the link from there to PJ Online can only be viewed by paid up subscribers meaning that is difficult to ascertain what question was actually asked and of whom. How convenient! (I see they have now finally posted the link - I will blog on this very soon)

Healthcare Professionals for Assisted Dying backed by Dignity in Dying, the former Voluntary Euthanasia Society, have flooded this year’s BMA annual meeting with motions calling for doctors to take a neutral stance on assisted suicide and euthanasia.

It has been carefully engineered to coincide with two high profile cases being heard in the high court next week, plans for a new private members bill and a mass lobby of parliament by the pro-euthanasia lobby on 4 July.

The majority of doctors and the major medical royal colleges (RCGP, RCP and Association for Palliative Medicine) however remain strongly opposed to a change in the law and British parliaments have three times in last six years, twice in the House of Lords and once in Scotland, voted against the legalisation of assisted suicide.

The BBC this morning reports a BMA spokesperson saying that the organisation is 'firmly opposed' to the legalisation of assisted dying adding: 'If assisted dying was legalised, effective safeguards could not be implemented without the involvement of doctors. It is therefore appropriate for doctors to voice their views on this issue.'

A powerful article in last week’s BMJ by Iona Heath, president of the Royal College of General Practitioners, argued strongly against a change in the law and is well worth studying.

Heath eloquently voiced her ‘deep concern that it will be impossible to draft a law robust enough to protect the vulnerable’ and expressed her discomfort ‘that medicine seems once again to be preparing to offer a technical solution to an existential problem’.

‘One of the huge challenges of human life’, she argues, ‘is to find ways of living a meaningful life within the limits of a finite lifespan that will always involve loss of love and the inevitability of grief. Doctors have a regrettable tendency to ignore this reality and to persist in active and invasive treatment beyond the point at which it has become futile and even cruel.’

She acknowledged that some of the drive to legalise assisted suicide and euthanasia is driven by fears about inappropriate invasive treatment but insisted that the right answer is not changing the law, but rather better care that recognises the limits of medicine.

She concludes:

‘When doctors fail to recognise and acknowledge existential suffering in the dying and take refuge in excessive technological interventions, patients become frightened and, no longer able to trust their doctors, may request assisted dying. But two technological wrongs do not make an existential right. I don’t want assisted dying, but I also don’t want a PEG tube.’

Any change in the law on assisted suicide and euthanasia would place pressure on vulnerable sick, elderly and disabled people to end their lives for fear of being a financial or emotional burden on loved ones.

This is the very last thing we need at a time when many families and the health service itself are already under considerable financial pressure.

Doctors should see this latest move for what it is and firmly reject it.

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Kiwi, Christian and Medical

This blog deals mainly with matters at the interface of Christianity and Medicine. But I do also diverge into other subjects - especially New Zealand, rugby, economics, developing world, politics and topics of general Christian and/or medical interest. The opinions expressed here are mine and may not necessarily reflect the views of my employer or anyone else associated with me.

About Me

I am CEO of Christian Medical Fellowship, a UK-based organisation with 4,500 UK doctors and 1,000 medical students as members. The opinions expressed here however are mine, and may not necessarily reflect the views of CMF or anyone else associated with me.